2025 ICD-10-CM code R78.8
Finding of other specified substances, not normally found in blood.
Medical necessity is established by the clinical indication for the blood test, the correlation between the abnormal finding and the patient's symptoms, and the plan for further investigation or treatment.
Clinicians are responsible for ordering appropriate blood tests, interpreting the results accurately, and documenting the findings clearly in the patient's medical record. They should also follow up on abnormal results to determine the cause and appropriate course of treatment.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R70-R79: Abnormal findings on examination of blood, without diagnosis
In simple words: This code signifies the presence of a specific substance in the blood that isn't typically found there.For instance, it could be used if a test reveals an unusual level of a certain metal, like lithium (often used to treat mental health conditions), indicating a potential overdose or other issue.
Finding of other specified substances, not normally found in blood. Use additional code to identify the any retained foreign body, if applicable (Z18.-). Excludes2: mental or behavioral disorders due to psychoactive substance use (F10-F19).
Example 1: A patient being monitored for lithium toxicity exhibits elevated blood lithium levels., A routine blood test reveals the presence of a heavy metal, prompting further investigation for environmental exposure., A patient presents with unusual symptoms, and a comprehensive blood panel identifies an uncommon substance, leading to a diagnosis of a rare metabolic disorder.
Documentation should include the specific substance found, the date and time of the test, the test method used, the result value, and any related clinical findings or symptoms.
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